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Vulvovaginal Chronic Graft-Versus-Host Disease With Allogeneic Hematopoietic Stem Cell Transplantation

From the ¹Reproductive Biology and Medicine Branch, National Institute of Child Health and Human Development, and ²Dermatology Branch, National Cancer Institute (NCI), ³Hematology Branch, National Heart, Lung, and Blood Institute, ⁴Experimental Transplantation and Immunology Branch, Center for Cancer Research, NCI, ⁵Pediatric Oncology Branch, Center for Cancer Research, NCI, Bethesda, Maryland.

ABSTRACT

OBJECTIVE: To describe the diagnosis and management of female genital chronic graft-versus-host (GVH) disease, a complication of hematopoietic stem cell transplantation.

METHODS: From 1999 to 2006, 33 women with vulvar symptoms or undergoing systematic evaluation for chronic GVH disease were referred 267 (median, range 29–6,117) days after transplantation for gynecologic evaluation. Pertinent histories, laboratory tests, and skin and genital area–directed examinations were performed. Vulvar disease was treated with superpotent topical glucocorticoids and topical estrogen. Sexually active, menopausal women used vaginal dilators, topical glucocorticoids and estrogen, and estrogen vaginal rings for vaginal synechiae.

RESULTS: At presentation, most patients complained of vulvar pain during urination and pain that prevented sexual intercourse. Twenty-nine of 33 presenting with vulvovaginal chronic GVH disease had vulvar erythema, with additional signs including vulvar vestibulitis syndrome (n=9), vulvar erosions (n=12), vulvar scarring (n=2), and vaginal scarring (n=6); over time, eight additional patients developed vaginal scarring. Topical glucocorticoids improved vulvar symptoms, and estrogen decreased vulvar mucosal friability. Eleven of 12 patients, who wanted to resume having intercourse, responded to nonsurgical treatment for vaginal synechiae.

CONCLUSION: A combination of topical superpotent glucocorticoids and estrogen was effective in the treatment of vulvovaginal chronic GVH disease. In those with vaginal scarring, use of a vaginal dilator and estrogen ring was helpful. Early identification and treatment of vulvovaginal chronic GVH disease ameliorates vulvar pain by healing eroded vulvar mucosa and may prevent the need for surgery for hematocolpos.

LEVEL OF EVIDENCE: III